When Pain, Opioid Use, and Mental Health Intersect

Academy of Integrative Pain Management (AIPM) President Clay Jackson, MD, opened the 2018 Global Pain Clinician Summit in Boston by outlining a series of misconceptions facing the opioid crisis. One such misconception—that chronic pain and mental health are often separate modalities—formed the basis for the summit’s Town Hall session on pain, opioid use, and mental health. The analogy of a “three-headed monster” from Greek mythology known as Cerberus, or the hound from Hades, was used to address the intersection of these three challenges in pain management.

“The correlation between chronic pain and mental illness is bidirectional,” said Dr. Jackson, and in many cases, if you are looking for a common cause or the so-called “mouth of the Mississippi, it begins with adverse childhood events.” Dr. Jackson explained that much like the US culture’s claim that “Everything I need to know I learned in kindergarten,” the same can hold true for pain, in that “Everything I feel, learned before age 5,” he said.

More and more, long-term research is showing that sources of chronic pain, opioid abuse, and comorbid mental illness largely stem from adverse childhood events such as abuse, separation from families, hostile living conditions, and extreme poverty, he explained. “It may be odd to hear this metaphor at a pain conference,” Dr. Jackson told the audience, “but it is indeed the third head of the dog. By addressing these issues now, we won’t necessarily solve the opioid problem today, but we may do so for the next generation.”

With this introduction and metaphor in mind, AIPM Executive Director Bob Twillman, PhD, launched the two-part Town Hall on chronic pain, opioid use, and mental health consisting of an overview and a question-and-answer panel session, both of which are summarized below.

The Three Ugly Heads of Pain Management

Many pain practitioners may feel they have been walking a tightrope the past few years as they have tried to balance helping their patients with pain, only to find themselves at the end of that rope facing Cerberus, said Dr. Twillman. The three “heads” the community is grappling with include:

Chronic pain: 50 million live with it; 25 million are high impact and 10 million disabled

Opioid Use Disorder (OUD): 12.5 million Americans are affected per year

Mental Health: 25 million with non-substance use disorder diagnosis and 6 million with a serious diagnosis.

These heads are chained not only by their high numbers but also their high management costs and high rate of related deaths. To further complicate matters, they reside among a series of social determinants, including low educational achievement, low economic opportunity, generational poverty, few community supports, and low degree of social connectedness. These problems are all similar in terms of prevalence, cost, stigma, complexity, lack of understanding, and need for a biopsychosocial approach, but most importantly, said Dr. Twillman, they all involve tremendous suffering. To solve this and prevent it from becoming a zero-sum game, the pain community needs to work together, he urged.

The simple solution of “just don’t prescribe opioids” does not work. As the healthcare community now knows, the numbers being reported are not 100% reliable, and many of the highlighted opioid overdose deaths are related to illicit substances, not prescribed medications, noted, Dr. Twillman. “Once we fully understand the data, we can better craft solutions.”

Mental heath is a large piece of the treatment puzzle and pain specialists know just how comorbid these disorders are among the chronic pain population. The risk of opioid overdose in those with PTSD, for example, is much higher, compared to those without PTSD, shared Dr. Twillman. In fact, among those patients with chronic pain who die of overdoses, they are more likely to have mental health diagnoses. Referring again to the three-headed dog analogy, Dr. Twillman said, “If we don’t attend to all of these issues, one of them is bound to come back and bite us.”

How to Manage Pain from Here

In 2014, an NIH panel concluded: “What was particularly striking to the panel was the realization that there is insufficient evidence for every clinical decision that a provider needs to make regarding the use of opioids for chronic pain, leaving the provider to rely on his or her own clinical experience” (see full report at https://prevention.nih.gov/sites/default/files/documents/programs/p2p/ODPPainPanelStatementFinal_10-02-14.pdf.) This was really not a helpful point for clinicians, noted Dr. Twillman, but perhaps, he said, the takeaway is that opioids need to be used in the right context. “Not everyone needs opioids for breakfast, lunch, and dinner,” he said,” but not everyone doesn’t need opioids either.” Patient education, comorbidities, mental state, provider direction, and informed decision-making are all tools that need to be put into play when considering prescribing opioids for chronic pain.

For the most part, available standards for assessing and treating chronic are logical, but how these standards were interpreted and implemented in previous years led to things getting out of hand, he pointed out. What we need to be striving for now is comprehensive integrative pain care as constructed by the 2017 AIPM Inaugural Integrative Pain Care Policy Congress (see www.integrativepainmanagement.org/page/PainPolicyCongress).

In the meantime, the pain community cannot afford to simply wait for more quality evidence to be developed. While that information is central, the reality is that every research paper ends with the same conclusion: “More research is needed.” More studies will always be pursued, leading to tweaked understanding and approaches along the way, but providers have a commitment to help patients who are in need right now. The best pain practitioners can do, offered Dr. Twillman, is to offer a team-based, multi-tool, patient-empowered treatment plan that strives for the most successful outcomes. Certainly, this goal comes with increased multi-disciplinary collaboration, referral networks, and better payer models (eg, bundled payment systems vs fee-for-service) but moving in this direction is not unachievable (see a related AIPM Meeting Highlight on Overcoming Barriers to Integrative Care ).

Audience Q&A: Challenges from the Clinicians’ Points of View

After Dr. Twillman’s overview, he moderated a town hall style discussion between a panel and the AIPM audience. Panelists included:

Daniel B. Carr, MD, who has a primary appointment in Public Health and secondary appointments in anesthesiology and medicine at Tufts Medical School, where he is also the founding director of the program on pain research, education and policy.

Andrey Ostrovsky, MD, a pediatrician and the CEO of Concerted Care Group, a comprehensive opioid treatment program based in Maryland.

Vanila Singh, MD, MACM, chief medical officer for the Office of the Assistant Secretary for Health at the US Department of Health and Human Services (HHS). Dr. Singh is also chairman of the Best Practices Interagency Pain Task Force.

Below are a few highlights.

What is the Value of Cross-Training in Addiction Medicine?

Dr. Carr addressed this question by pointing out that part of how the healthcare community got to its current situation has to do with having too narrow a definition of pain. “When we think about pain in a single way, we are missing half of the equation,” he said. A tissue injury or sensing a tissue injury must also be considered with, for example, distress, abandonment, isolation, aloneness, etc., as the human experience of pain involves both halves.” Then, the questions around Are they an addict? Are they also in pain? What is their mental health status? can be addressed. Just examining one may put a pain practitioner on the wrong path. “So yes,” he responded, “we should be trained in both pain medicine and addiction to untangle a lot of the current problems that stem from an oversimplified language.”

Dr. Singh agreed, noting that having more training and knowledge helps clinicians to better assess and better flag someone who may be at risk. Knowing when to refer to a specialist is important as well, she said.

Dr. Ostrovsky shared a challenge he has faced in this regard when trying to grow practice collaboration with local Opioid Use Disorder (OUD) recovery programs. Specifically, he said he was surprised to be denied requests for collaboration due to deemed business competition. He questioned why clinicians would not want to share expertise for the betterment of the patients as a priority over finances and went on to urge that the business model of medicine has to change. “Bundles may not be enough,” he said, “and the area where this is needed most is in addiction medicine. We need to be incentivized by doing the best thing for the patient.”

An audience member reiterated the need to tackle the source of many addiction problems—that is, those stemming from childhood. There are many opportunities, such as educating teachers and using tools like gaming which engage children, that could be used to educate individuals about the risks of addiction from a young age—without re-creating the wheel.

How Do We Know When a Patient Needs Help in All 3 Areas (ie, Chronic Pain, Opioid Use, Mental Health)

“It’s all about the history,” said Dr. Singh. “If the patient is comfortable and at ease, the patient will likely share with you what they are going through and you will learn there are issues at play. That time is necessary to treat the whole patient.” Pre-appointment patient surveys offer an additional platform to check off challenges and can enable clinicians to get into childhood trauma or other issues the patient is experiencing. “Bringing in a team and talking honestly about opioids and other approaches comes with trust,” she noted, adding that these types of integrative relationships can also help to avoid physician burnout.

Dr. Ostrovsky responded to this topic by focusing on patient assessment tools. “Most of the screening tools for OUD risk don’t ask key questions—such as, ‘Do you know where your next meal is coming from?’ or ‘Do you know where you will sleep tonight?’” Some doctors struggle with the decision to either spend time screening the patient with a tool or listening to the patient. Being able to fully screen, perhaps through software, may improve these assessments going forward, he suggested.

Dr. Singh added to Dr. Ostrovsky’s point by emphasizing that the tools practitioners use are useful for gathering data and following important trends, but when thinking of the individual patient, many of them do not want to sit with an iPad and answer 50 questions when they are in pain and feel they are not getting access to treatment. “We need to find a way to get around screening fatigue and frustration—for both the patient and the provider,” she said. While telehealth and mobile health apps have great possibilities, she noted, clinicians need to find a way to better engage our patients and gather the information needed.

An audience member who practices interventional pain medicine said he agrees that additional training will help clinicians assess the full patient, but stressed they should be able to do this out of choice, and not because of a legal or policy requirement. “We, as specialists, are exceedingly more trained in what we are doing than those who are trying to control us…. We are doing ourselves a disservice when we give power away. If you want to do pain management, get trained, but don’t be mandated to have to do something to do it,” he said.

Another audience member questioned how practitioners can best get the patient involved in doing what is best for them, noting that some patients enter a clinic assuming that they have an option or right to pick from “some sort of pain management menu.” Some patients just want a specific medication and do not wish to talk to anyone about what they are going through, he said. Dr. Ostrovsky commented that the science around contingency management might help clinicians to better meet patients where they are, including in common situations like these.

Added Dr. Carr, “Now is the opportune time to inform legislators that we need updated, more integrated standards…. There needs to be a reframing of the standard of care for chronic pain so that the expectations and policies are not just around opioids but also around mental heath and a host of other biopsychosocial issues.”

To be frank, commented Robert Bonakdar, MD, FACN, from the audience, “We recognize these standards of care, but the insurance payers do not.” Dr. Bonakdar is an AIPM past president and current director of pain management at the Scripps Center for Integrative Medicine in La Jolla, California.“How we do change the discrepancy between evidence-based care standards and coverage?” he asked the audience.

Dr. Carr suggested that the field of psychiatry might offer a useful example. Currently, he said, that industry is re-examining how disorders like anxiety and depression are diagnosed to move away from a narrow checklist of criteria and toward an understanding of evidence-based mental comorbidities so that clinicians are not stuck treating a patient based on a specific reimbursement model.

How Do We Solve the “Opioid Refugee” Problem?

In the current pain management environment, many chronic pain patients are finding that they are no longer able to get needed opioids from their prescriber. They are forced to doctor shop or turn to the black market. How can these so-called “opioid refugees” be addressed, asked Dr. Twillman.

One audience member suggested that proper tapers from opioids could provide a potential solution. “Sometimes, providing direction away from opioids is key, but” he said, “guiding their speed is just as important.” When tapering a patient off of chronic opioid therapy, doing it in the right manner may help to avoid increasing the number of opioid refugees.

Dr. Singh addressed the issue by noting: “We should be aiming to have excellent pain care in our society, but we also have to endeavor to ensure that even one overdose fatality is too many…. It’s a false choice to say we can offer either pain care or addiction treatment—there is an intersection but they are not synonymous When individuals cannot find someone to provide medically supervised treatment for legitimate reasons, then where do they go?.… Our efforts must be to ensure that both issues are addressed.”

Summed up Dr. Ostrovsky, “We need to be careful not to swing the pendulum from all opioids to no opioids.”

Dr. Twillman disclosed he is a consultant to Millennium Health. Dr. Jackson disclosed that he is a consultant for Otsuka Pharmaceuticals.

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